Inspection on 03/10/07 for 112 Wellington Road

This inspection was carried out on 3rd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

112 Wellington Road 02/12/08

112 Wellington Road 22/07/08

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 112 Wellington Road Bilston Wolverhampton WV14 6AZ Lead Inspector Deborah Sharman Key Unannounced Inspection 3rd October 2007 10:30 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 112 Wellington Road Address Bilston Wolverhampton WV14 6AZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01384 410418 info@Inshoresupportltd.com Inshore Support Limited Ms Avril Lorraine Taylor Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care (excluding nursing) and accommodation for service useres pf both sexes whose primary care needs on admission to the home are within the following categories: Learning Disability (LD) 3 The maximum number of service users to be accommodated is 3. 2. Date of last inspection This is a new service. This is its first inspection. Brief Description of the Service: 112 Wellington Road is based in the Bilston area of Wolverhampton and is registered as a care home providing personal care and accommodation for 3 younger adults with learning disabilities. It is part of the Inshore Support Ltd group of housing whose main office is in Halesowen. The home is located close to the centre of Bilston on the main A41 road with good local amenities including access to the metro tram within a twominute walk. It opened in 2007 and consists of a two-storey domestic style terraced property. Each person living at the home has a single room with washbasins. Bathroom and separate toilet facilities are available for shared use. There is a private pleasant garden with patio seating area at the rear of the property. Residents need to be able to access stairs as bedrooms are on the first floor with no lift facilities. The two bedrooms are both for single occupancy with bathrooms and toilets close by. There are two lounges, a kitchen and dining area. There is a smallenclosed garden to the rear of the house. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this unannounced key inspection between 10.30 am and 5.15 pm. As the inspection visit was unannounced this means that no one associated with the home received prior notification and were therefore unable to prepare. As it was a key inspection the plan was to assess all National Minimum Standards defined by the Commission for Social Care Inspection (CSCI) as ‘key’. These are the National Standards, which significantly affect the experiences of care for people living at the home. Prior to inspection CSCI were provided with written information and data about the home in their annual return. This information was analysed prior to inspection and helped to formulate a plan for the inspection and has helped in determining a judgement about the quality of care the home provides. Questionnaires were not sent out to people living at the home because pre inspection information indicated that due to the nature of their disabilities that they would not be able to provide feedback about their experiences since moving in, in this way. During the course of the inspection the Inspector used a variety of methods to make a judgement about how service users are cared for. The Registered Manager was not available so the senior staff member initially supported the inspection. The Deputy Manager arrived a little later and was present throughout the inspection day to answer questions and generally support the process. The Inspector talked to a number of care staff, observed care practice and toured the environment. The three people living at the home are none verbal but one person took the Inspector to show her bedroom and adjacent bathroom. This is a new service and this inspection was the first. The home is registered for three people and there are no vacancies. The Inspector assessed in detail the care provided to one resident and aspects of care provided to the two others using care documentation and sampled a variety of other documentation related to the management of the care home such as training, staff supervision, maintenance of the premises, accidents and complaints. Since inspection, questionnaires have been sent out to staff and at the time of writing their return is awaited. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There was little evidence of how service users cultural needs are met. A Sikh service user is eating beef regularly for example and it is not known whether this is acceptable to her. Staffing levels are compromising activities, which are currently insufficient and not based upon individual needs, interests and preference. Assessment of medication showed the need to review systems to ensure that service users receive their medication as prescribed and that medication records account for this with integrity. There was a lot of evidence that staff are generally managing behaviours appropriately through diversion and distraction techniques. There were two incidents however, which gave cause for concern. These highlighted less understanding of service user needs, choice, rights, non adherence to the plan of care and a range of issues in relation to physical intervention. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4. Quality in this outcome area is adequate. Prospective service users are given ample time to become familiar and comfortable with new staff and the new environment before moving in. More attention could be paid to assessing risk and service users cultural needs prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Written information about services is available. The Statement of Purpose would benefit from including the categories of registration and the range of needs the home intends to meet. Consideration should also be given to producing the Service User Guide in formats which are more readily accessible to the service user group. From discussion with staff and from sight of records it was established that people, prior to their admission, visited the new premises on many occasions to familiarise themselves before they moved in. Staff also worked alongside them for many weeks in their previous care accommodation to get to know them and to learn how to best meet their needs. Written information was obtained from a range of sources to illustrate the service users needs but there is not a formal assessment undertaken by the manager and the detail of cultural needs appears to have been overlooked. Risk assessments were not 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 10 completed until four months after admission which provides the potential for harm in a new environment as risks have not been identified and controlled in a timely manner. All three service users appear to be settling in well. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is adequate. Care plans and risk assessments are being developed. The format provides a good foundation upon which to build. They must however be completed, must reflect changing need and must be adhered to in order to ensure that service users needs and interests are met at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans have been obtained from the service users previous care accommodation and are available for reference. 112 Wellington Road are in the process of updating these and those that have been completed have been done to a generally good standard with a good level of detail to guide staff. Care plans that address a range of cultural issues and needs are required to help staff know how to meet need. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 12 Care plans are in place to help staff to know how to manage behaviour. These acknowledge that behaviour is a form of communication and direct a nonaversive approach. A multi disciplinary review has been held to monitor and review the service users needs following admission and it was positive that minutes were available. Inspection has shown the need to ensure that care plans are adhered to. For example a health care plan states that a service users goal is to lose weight and that she should be weighed weekly. Records show her to be weighed fortnightly and to be increasing in weight. Records show behaviour plans to be mostly complied with to good effect but concerns identified in incident records that show a disregard for choice are discussed later in this report. Some records evidence where service users choices have been respected e.g. when the decision to have a lie in and not get out of bed has been facilitated. Risk assessments are being developed but do not yet reflect all the identified risks. Risk assessments have not been implemented following concerns, which have been referred through adult protection procedures. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is adequate. Staffing levels are restricting service users social inclusion. Whilst some outcomes are poor, this has been judged as adequate overall on the basis that the home recognises this and plans to make some changes to improve opportunities for service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users do not attend traditional day care provision and are dependent upon this service to arrange and provide all leisure activity. Several sources identify that staffing levels need to improve to better support the provision of activities: At the point of the home’s registration with CSCI it was agreed that in addition to one to one staffing, seven hours staffing would be available to assist with social inclusion. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 14 The provision of activities is poorly evidenced in the home’s annual return to CSCI. A regulation 26 report in August 2007 states that staffing levels are to be addressed. Staff who spoke to the Inspector believe that steps are underway to appoint someone to this post. Activity records evidence at most two trips away from the home per week and often this is for a drive. A staff member told the Inspector that residents go out 2 –3 times per week and they try to take the residents out for a drive when staffing levels prevent a proper activity or trip. An additional member of staff worked on the day of inspection to ensure that a service user could go out for a lunchtime meal to celebrate her birthday, which had been the day before. The service user has also received a visit from her family. Service users would benefit from assessment of their spiritual needs so that where applicable, plans can be made to meet those needs. Staff are satisfied with the allocated food budget and service users and staff go together to the supermarket to buy food weekly. Food records show the provision of a range of meals with records showing the service user case tracked to have had a different breakfast every day including a cooked breakfast from time to time. There is nothing within the care plan for a Sikh service user to indicate her attitude to eating beef. Discussion with the Deputy Manager showed that this had not been considered and there was plenty of information within food records to show that she is eating beef regularly. Her need to have food chopped is known. The goal to support her to lose weight is not working yet and a nutritional screening tool referred to in the care plan had not been completed. The homes annual return states that service users have access to all communal rooms indicating that they have freedom of movement. However an incident where staff physically intervened to remove the service user from the bath, which she is known to enjoy does not best evidence freedom of choice and movement. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is adequate as performance is mixed. Service users present as well groomed with individual style but bathing as a relaxing activity rather than a care task needs to be respected for those who value this. Changes in health are identified and responded to. Medication practice requires review to ensure that medications are administered as prescribed and accounted for accurately in records to promote the health and safety of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents present as well groomed with individual style. Records show service users are supported regularly to bath or shower. Bathing care plans are detailed and the physical care tasks are broken down in detail. It would be positive to see these care plans include attention to bathing as a relaxing pleasurable activity rather than just a physical task. Review minutes for the service user case tracked describe how much she enjoys her bath as an aid to relaxation. This does not appear to have been considered by staff when they 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 16 encouraged her to get out of the bath, which lead to the service user presenting challenging behaviours. This, in turn lead to staff physically removing her from the bath escalating rather than diffusing a situation which need not have arisen and which was potentially unsafe. Health needs are represented well in service users health action plans. Service users have had initial check ups as part of the process of registering with a new GP. The service user case tracked has received other routine health screening and received medical attention following a change in health which staff were concerned about. Medication practice requires review. Positive aspects include good secure storage arrangements and a system that accounts well for the management of the medication keys. Medications are recorded into and out of the premises and all the medications prescribed were in stock. Improvements to some aspects are needed however. Protocols are not in place to guide the administration of medications prescribed ‘as required’. Guidance will assure that these will be administered consistently and in the service users best interests. A comparison between medication stocks and Medication Administration Records indicated that medication is missing without being signed for and that medication which remained in stock had been signed for. This indicates that the service user had not received the medication as prescribed and this has the potential given the drug involved to impact adversely on the service users behaviour and state of well being. A blister pack system is in use. Before this was established medication had been administered from boxes, which have not been returned. It appears that night staff have continued to use medications from the boxes in preference to the blister pack. The other possible explanation is that the medication has not been administered at all. Operating two systems simultaneously increases the risk of error. The Inspector left the Deputy Manager to investigate the various issues identified. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is adequate. Information about how to make a complaint is available but not readily accessible to service users and others. Systems to underpin service user protection must improve to ensure that staff have the knowledge to identify and respond to any abuse or poor practice appropriately. This will better assure service users protection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints have been received to date since opening but appropriate systems are in place to respond should a complaint be made. Complaints information is in an easy read format but would benefit from being publicly available. A range of safeguarding policies is available to guide staff to minimise the risk of abuse and to provide guidance in the event of a concern being raised. The service would be obliged to report any allegation or concern under Wolverhampton’s multi agency safeguarding policy but a copy was not available and should be sought. The homes own policy does not include CSCI in its reporting guidance and as there is a regulatory duty to report any abuse or alleged abuse to CSCI the inclusion of this in guidance will ensure sufficient action is taken in the event. The physical intervention policy is brief and would benefit from review against the Department of Health and the British Institute of Learning Disability’s 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 18 guidelines. This policy on the prevention and management of violence and aggression states; ‘Restraint procedure will be individually designed with the involvement of key staff and psychology services. Each procedure will be documented in a written plan of care’. This was not in place for a service user who was physically removed from the bath by staff because she didn’t want to get out and began to communicate this through behaviour. It is not clear why she had to get out when this is an activity she is known to enjoy. The intervention was not recognised as a restraint or physical intervention as it was not reported to the manager on duty, was not recorded on physical intervention paperwork and was not reported under regulation 37 to CSCI. Furthermore it appears that she may have been removed from the bath using an underarm lift, which is a banned move. The Inspector left the Deputy Manager to investigate this who believes both staff involved to be appropriately trained in MAPA although at the time of inspection evidence of this was only available for one of the two staff members. An additional incident where it is evident staff require support to promote rights and diffuse rather than escalate situations is where the service user was told to stop a known behaviour and if she didn’t stop she wouldn’t be allowed to go out. A situation between two service users has been reported to Social Services under adult protection procedures. The Deputy Manager was able to describe supervision measures put in place to minimise further risk but this has not been formalised in records. The Inspector observed the service users being supervised as described. The Inspector was told that the Manager and Deputy Manager have completed adult protection training. As this is a new service and a new team most staff have not received training in adult protection and this must be prioritised. Appropriate accounting systems are in place to safeguard service users possessions and financial interests. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome area is good. Service users live in a modern property which has been refurbished to a high standard and which meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The premises have been refurbished and have been finished to a high standard. The property is domestic in style, blends in well with the local community and provides sufficient space and good quality furnishings to ensure service users comfort. Attention has been paid to the environment to make sure that it is safe to meet the needs of people whose behaviour can challenge. Pictures for example are secured discreetly to walls and TVs are within domestic style cabinets but behind Perspex. Known behaviours of service users have been taken into account and steps taken to obscure glass to protect their privacy. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 20 On arrival the Inspector detected a slight urine odour in the front room. Managers have identified this previously as a problem and to their credit action has been taken promptly to try to address this by removing new carpet and replacing with more readily cleanable laminate flooring. The Inspector was told that the washable three-piece suite is washed regularly but with the odour still present the adequacy of the cleaning regime should be reviewed. A tour of the premises showed the premises including the garden to be tidy and well maintained. A service user was seen to be enjoying sitting in the garden. Repairs are identified and processed for action. There were no obvious hazards other than a step which is half way down the ground floor hall way and which on the day of inspection a service user slipped and fell heavily from. Review of the step following the accident showed that although the flooring differs from the top to the bottom level of the step, the colours blend and are not easily distinguishable and do not make the presence of a step evident. This should be reviewed. Water from some outlets is exceptionally hot. Staff said that service users never access taps independently but this has not been risk assessed. Likewise not all windows are secured and this has not been risk assessed based on service users vulnerabilities. Environmental risk assessments are minimal and need to be developed. Clinical waste systems are in place and staff confirmed the ready availability of protective clothing for use whilst they are supporting service users with personal care. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36. Quality in this outcome area is adequate. Staff feel well supported on a day to day basis but are being provided in numbers sufficient to ensure safety rather than quality of opportunity currently. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels have been discussed earlier in this report under ‘lifestyle’. Staff are being provided on a one to one basis during waking hours but an additional day staff member is required to support social inclusion and activity as two of the service users require support on a two to one basis when out. Staff are safely recruited and feel supported but there is capacity for improvement in the provision of formal supervision. One staff member who had been in post for longer than others has had 3 recorded supervisions with a line manager. A staff member who had been employed for 6 weeks confirmed having had a supervision session and records were available. There was no evidence of supervision having been provided for another staff member who has been in post for four months. Consistency in supervision needs to be achieved. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 22 Training is available to staff but was difficult to evidence with any clarity at this inspection. A team-training matrix was not available and certificates were not always available on staff files. Induction systems to national standard are available but cannot always be provided in a timely manner. However 40 of care staff hold a nationally recognised care qualification and this is just short of the national target of 50 . Outcomes from this inspection show how some staff need support to develop their value base and understanding of physical intervention. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is adequate with more strengths than weaknesses. Some good management systems have been established in a short time since the home opened. Key areas for improvement have been identified for action within this report for review and action to ensure full compliance with the regulations and improved outcomes for service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager is working towards a recognised national qualification to equip her for her role. Staff spoken to recognised the manager’s strengths and ability to communicate and direct staff appropriately. Support is available to the home from more senior managers who complete robust regulation 26 visits and records and ensure that issues identified for improvement are acted upon. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 24 Although the home has only been open a short time steps have been taken to begin quality assuring and to date the Statement of Purpose has been subject to quality checking with a plan to complete more over time. Service maintenance certificates requested were available although it was not known whether water safety had been checked. Risks from hazardous chemicals are assessed and managed well. A first aid box is available and staff know its location. Three of the management team are first aid qualified and the Deputy manager is aware of the need to organise such training for the staff group. The Fire Service and Environmental Health Departments conducted inspection visits prior to the home opening. Managers must ensure that all accidents are recorded. There is evidence from comparing care records with the blank accident book that this is not happening. The range of environmental risk assessments is very limited and this needs some work to identify and minimise any risks based upon the vulnerabilities of the service users. Any incident including physical intervention, which affects the welfare of people living at the home, must be notified to managers and subsequently without delay to the Commission for Social Care Inspection. All staff cooperated fully throughout the inspection and in the absence of the manager, the Deputy manager responded positively and accepted feedback given. The Inspector advised that CSCI need to be informed about the management arrangements for the home should the manager be absent for 28 days or more. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 1 13 1 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 2 X X 2 X 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 26 NA Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA3 Regulation 12 Requirement Steps must be taken to ensure that the care home is conducted with due regard to the religious persuasion, racial origin and cultural and linguistic background of service users. Risk assessments must be carried out that reflect the full range of risks to service users. This will help to minimise risk of injury or harm to service users Arrangements must be made to enable service users to more fully engage in local, social and community activities. This will ensure that service users quality of life improves. Medication practice must be reviewed to ensure its safe administration in accordance with prescribed direction and that medication records accurately reflect medication administered. This will better promote the health and safety of service users. 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 27 Timescale for action 30/11/07 2 YA9 13 31/10/07 3 YA13 16(2)(m) 31/10/07 4 YA20 13(2) 31/10/07 5 YA23 13(7)(8) Steps must be taken to ensure 04/10/07 that no service user is subject to physical restraint unless restraint of the kind employed is the only practicable means of securing the welfare of that or any other service user and there are exceptional circumstances. This will promote residents safety, rights and choices. On any occasion in which a service user is subject to restraint, the registered person shall record the circumstances, including the nature of the restraint. This will ensure that any physical interventions are properly accounted for and monitored in the interests of service users. Arrangements must be made, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse to ensure safety and well being. Steps must be taken to keep the care home free from offensive odours to ensure that the premises provide a pleasant living environment for all where risk of infection cross contamination is minimised. Staff must be provided in sufficient numbers to support service users’ assessed needs at all times. This will ensure that service users are properly supervised and are provided with appropriate opportunities. Steps must be taken to ensure DS0000069681.V345516.R01.S.doc 6 YA23 13(6) 31/10/07 7 YA24 16(2)(k) 31/10/07 8 YA33 18 30/11/07 9 YA42 17(1)(a) 04/10/07 Page 28 112 Wellington Road Version 5.2 Sch 3 that a record of any accident affecting the service user is kept including the nature, date, time, whether medical treatment was required and the name of the persons who were respectively in charge and supervising the service user. This will better account for accidents and will enable an analysis of accident trends to help to identify and minimise arising risks. Steps must be taken to ensure 30/11/07 the health and safety of staff and service users environmentally by ensuring that: All parts of the care home to which service users have access are as far as reasonably practicable free from avoidable risks And: Unnecessary risks to the health and safety of service users based on their vulnerabilities are identified and as far as possible eliminated. This will safeguard service users from risk of accident and injury. 10 YA42 13(4) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations The Statement of Purpose should include the category of DS0000069681.V345516.R01.S.doc Version 5.2 Page 29 112 Wellington Road people it is registered to accommodate and explain the range of needs it is able to meet. The Service User Guide should be made available in alternative formats so they are accessible to service users. All medication errors should be investigated and acted upon. All complaints procedures including easy read formats should be publicly available within the premises. 2 3 YA20 YA22 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 112 Wellington Road DS0000069681.V345516.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!